Event Notification Report for March 01, 2023

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
02/28/2023 - 03/01/2023

EVENT NUMBERS
56297 56375 56377 56378 56379
Agreement State
Event Number: 56297
Rep Org: SC Dept of Health & Env Control
Licensee: Pactiv LLC
Region: 1
City: Jackson   State: SC
County:
License #: GL-0080
Agreement: Y
Docket:
NRC Notified By: Adam Gause
HQ OPS Officer: Brian Parks
Notification Date: 01/05/2023
Notification Time: 15:08 [ET]
Event Date: 12/07/2022
Event Time: 16:36 [EST]
Last Update Date: 02/28/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Deboer, Joseph (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 3/1/2023

EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTER AND INDICATOR FAILURE

The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via email:

"The South Carolina Department of Health and Environmental Control was notified via email at 1636 [EST] on 12/7/2022, that during a routine shutter check, a general licensed fixed gauging device was stuck in the closed position (fail-safe). The licensee reported that the general licensed fixed gauge device is a Kr-85 Thermo EGS Gauging Model SCL-77A (housing serial number 65675-2), with an activity of 37 gigabecquerels (1000 millicuries). Department inspectors were dispatched to the facility on 12/21/2022 to perform an on-site investigation. At the time of the visit, the licensee had already taken action by contacting a licensed vendor to repair the fixed gauge, and the gauge was placed back in service. The licensee also indicated that for the duration that the gauging device was stuck in the closed position, the production line was shut down, and the device was removed from service. Dose rate surveys of the fixed gauging device were performed by Department inspectors and indicated readings below the external radiation levels outlined in the sealed source and device registry.

"The South Carolina Department of Health and Environmental Control was also notified on 01/04/2023, that a separate general licensed fixed gauge device indicator had failed on 09/26/2022. The licensee reported that the general licensed fixed gauge device is a Sr-90 NDC Technologies Model 301 (housing serial number 8778), with an activity of 0.37 gigabecquerels (10 millicuries). The licensee reported the device has been repaired."

South Carolina Event Report ID No: EN 56297

* * * UPDATE ON FEBRUARY 3, 2023, AT 1022 EST FROM K. KOCI TO T. HERRITY * * *

The following update was provided by the Department via email:

"The information for the sealed source housed in the Thermo EGS Gauging device model SCL-77A, serial number 65675-2, is as follows: Kr-85, Amersham Model No. KAC.D1 (serial number RH443). (NMED Item No. 230011)

"The indicator was repaired on the same day of the discovery of the failure by Pactiv Corporation. In order to complete the record, the Department has sent a request for additional information to the registrant to obtain the model and serial numbers for the sealed source housed in the Sr-90 NDC Technologies, Model 301 gauging device (serial number 8778). (NMED Item No. 230012)

"At this time, both [NMED] events are considered still under investigation."

Notified R1DO (Lally) and NMSS Events Notification via email.

* * * UPDATE ON FEBRUARY 28, 2023, AT 1517 EST FROM K. KOCI TO E. WEST * * *

"(NMED Item No. 230012) The model number of the Sr-90 sealed source housed in the NDC Technologies Model 301 gauging device is AEA Technology model number SIF.D1 (serial number NC406).

"Both events (NMED Item No. 230011 and NMED Item No. 230012) are now considered closed."

Notified R1DO (Bickett) and NMSS Events Notification via email.


Agreement State
Event Number: 56375
Rep Org: Ohio Bureau of Radiation Protection
Licensee: Acuren Inspection Inc. ADBA TEI
Region: 3
City: West Chester   State: OH
County:
License #: 03320990006
Agreement: Y
Docket:
NRC Notified By: Stephen James
HQ OPS Officer: Kerby Scales
Notification Date: 02/21/2023
Notification Time: 13:57 [ET]
Event Date: 02/20/2023
Event Time: 00:00 [EST]
Last Update Date: 02/21/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Feliz-Adorno, Nestor (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - STUCK SOURCE

The following information was received from the state of Ohio via email:

"On Monday 2/20/2023, radiographers from the licensee's Akron, Ohio office experienced a source that would not retract. There were two radiographers working on the job site when they realized that their source was not locking into the safe position. They contacted management at 1013 [CST] and were instructed to move their boundaries out and use physical barriers to prevent unauthorized access. When the licensee's source retrieval team arrived on site, they discussed the situation with the crew and began to form a plan for locating the source.

"The retrieval team located the source in the collimator and then developed a plan for a way to shield and retract the source. The retrieval team made 16 moves to shield the source before attempting retrieval. The source was locked in the safe, shielded position inside the camera at 1510.

"The source retrieval team found that the drive cable connector had broken just above the crimp causing the source and pigtail to become disconnected from the cable. The licensee reports that the connector lot number is FW-21, and it was put into service on 12/18/2022."

Ohio Item Number: OH230001


Agreement State
Event Number: 56377
Rep Org: Texas Dept of State Health Services
Licensee: University of Texas- MD Anderson CC
Region: 4
City: Houston   State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Kerby Scales
Notification Date: 02/21/2023
Notification Time: 21:35 [ET]
Event Date: 02/21/2023
Event Time: 00:00 [CST]
Last Update Date: 02/28/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 3/1/2023

EN Revision Text: AGREEMENT STATE REPORT - STUCK SOURCE

The following information was provided by the Texas Department of State Health Services (the Group) via email:

"On February 21, 2023, the Group was notified by the licensee's radiation safety officer (RSO) that a cobalt-60 source was stuck in the unshielded position. The source is used in a teletherapy unit for non-human experimental irradiation. The source is pointed towards the floor. The RSO stated they contacted their service company and was told it is probably caused by low air pressure as air pressure is used to drive the source. The RSO stated the source/unit was located in the basement of the facility. The RSO stated they performed radiation surveys in adjoining rooms and the room above where the exposed source is located, and all dose rates were normal (less than 200 microrem/hr). The service provider will be at the licensee's location on February 23, 2023, to inspect the unit. The access door has been locked and 'Caution' tape has been placed on the door jam. No over exposures have occurred due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-9991

* * * UPDATE ON 02/22/23 AT 2049 EST FROM ART TUCKER TO KERBY SCALES * * *

The following update was received from Texas Department of State Health Services (the Agency) via email:

"On February 22, 2023, the licensee's RSO notified the Agency that they had just talked with the service company that would retrieve the source and discussed the operation. The job is expected to start at 0830 CST on February 23, 2023. The RSO stated the individual will enter the room wearing a Personal Radiation Dosimeter (PRD), an OSL [Optically Stimulated Luminescence] dosimeter, and an Instadose for exposure monitoring. Alarms will be set on the PRD. The RSO stated they will have a pre-job safety briefing before the technician enters the room and will establish turnback values for the job. The technician will enter the room and rotate the source head to point the source away from them. They will then force the source back into the shield. The service company estimates the technician will receive 500 millirem for the job. The RSO stated the room has video surveillance and will also have audio capabilities. The RSO stated the job is anticipated to take less than 15 minutes. The RSO will notify the Agency when the technician enters the room for the first time and leaves the room when the job is completed. The Agency has requested additional information."

* * * UPDATE ON 02/23/23 AT 1307 EST FROM ART TUCKER TO IAN HOWARD * * *

The following update was received from Texas Department of State Health Services (the Agency) via email:

"On February 23, 2023, the licensee notified the Agency that the service company was able to return the source to the fully shielded position by manipulating the systems air pressure. No individual received any significant radiation exposure from the operation. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Roldan-Otero) and NMSS Events Notification via email.

* * * UPDATE ON 02/28/23 AT 2250 EST FROM ART TUCKER TO ERNEST WEST * * *

"The licensee's radiation safety officer provided the following additional information: `[The teletherapy unit that had a stuck source] is a Theratron 780C, and it was the Numatics Mark 8 solenoid valve that failed.'

"Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Vossmar) and NMSS Events Notification via email.


Agreement State
Event Number: 56378
Rep Org: Utah Division of Radiation Control
Licensee: Utah Valley Regional Medical Center
Region: 4
City: Murray   State: UT
County:
License #: UT 2500129
Agreement: Y
Docket:
NRC Notified By: Phillip Goble
HQ OPS Officer: Kerby Scales
Notification Date: 02/21/2023
Notification Time: 22:25 [ET]
Event Date: 02/21/2023
Event Time: 17:00 [MST]
Last Update Date: 02/21/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - LEAKING EQUIPMENT

The following was provided by the Utah Division of Waste Management and Radiation Control:

"On 2/21/23, at 1700 [MST], the Intermountain Heart Institute, Cardiac Molecular Imaging (CMI) Coordinator reported to the RSO [Radiation Safety Officer] that around 1630 a technologist, removing a Rb-82 generator from service, found liquid radioactive contamination in the bottom of the well chamber of the infusion system.

"A syringe was used to remove the saline from the well of the infusion system and the liquid was placed in the liquid radioactive waste storage. Decontamination procedures were followed. The infusion system well was wiped dry with paper towel(s). All radioactive waste was placed in approved radioactive waste storage. Wipe test(s) were performed. This incident has no impact on patient treatment. All quality control procedures passed while the generator was in use which verifies that patient treatments were within all requirements.

"The manufacturer was contacted for assistance, and it is planned that the generator will be shipped back for investigation. We will follow the manufacturer's instructions for the shipment. A new generator has been placed in the infusion system so that patient care can continue today."

Utah Event Report Number: UT23-0003


Agreement State
Event Number: 56379
Rep Org: Texas Dept of State Health Services
Licensee: Gulf Coast Growth Ventures LLC
Region: 4
City: Gregory   State: TX
County:
License #: L07102
Agreement: Y
Docket:
NRC Notified By: Arthur Tucker
HQ OPS Officer: Kerby Scales
Notification Date: 02/22/2023
Notification Time: 18:34 [ET]
Event Date: 02/22/2023
Event Time: 00:00 [CST]
Last Update Date: 02/22/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received from the Texas Department of State Health Services (the Agency) via email:

"On February 22, 2023, the Agency was notified by the licensee's service company that the shutter on a Vega SH-F2B was found stuck in the open position during routine testing. Open is the normal operating position. The gauge contains a 200 millicurie (original activity) cesium-137 source. The gauge does not present an exposure risk to members of the general public or plant workers. The manufacturer has been contacted to conduct the repairs to the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-9992

Page Last Reviewed/Updated Wednesday, March 01, 2023